TRACTION

IN ORTHOPAEDIC

Asep Santoso
HISTORY OF TRACTION
• Guy de Chauliac  continuous isotonic traction for the treatment of
fractures of the femur (600 years ago)
• The first really effective method  Sir Hugh Owen Thomas
NATHAN SMITH PRIOR TO THE AMERICAN CIVIL WAR
AND PUBLISHED IN 1867
HODGEN,1865
GURDON BUCK'S 1883
WITH THE DISCOVERY OF X-RAYS IN 1895

MALUNION

SKELETAL TRACTION
• Traction by skeletal Pin
introduced by Fritz Steinmann of Switzerland in 1907
• The first popular method of skeletal traction (Pearson in
1919 )
(1972)

(1929)
(1927)
 TYPE OF TRACTION

1. FIXED TRACTION
2. SLIDING TRACTION
- Skin traction
- Skeletal traction
 FIXED TRACTION
• The arrangement called Fixed traction when
counter-traction acts through an appliance
which obtains a purchase on a part of the
body
THOMAS SPLINT
ROGER –
ANDERSON WELL
LEG TRACTION

Fulcrum
SLIDING TRACTION
• The arrangement when the weight of all or part of
the body acting under the influence of gravity and
utilized as counter-traction

• Initial weight is 10 % of body weight

• The heavier the weightthe higher the end of the
bed must be raised (1 inch for 1 Lb)
LOWER EXTREMITY TRACTION
BUCK’S TRACTION

Max weight 15 lb (6,7 kg)

CONTRAINDICATION FOR SKIN TRACTION

• Skin abration/laceration
• Dermatitis
• Impairement of circulation
• Marked shortening

COMPLICATION:
Allergic, excoriation, pressure sore, common peroneal nerve palsy
• Bryant, in 1879, modified
Buck's method for the
treatment of fractures of the
femur in children.
• < 2 yo
• < 35-40 Lb (< 20 kg)
MODIFIED BRYANT’S TRACTION
• Abduction after 5 days
• 10o alternate days
• By 3 weeks in full abduction
TRACTION TREATMENT OF FEMORAL SHAFT
FRACTURES
 Charnley's modification of
CHARNLEY MODIFICATION OF
Thomas's traction for fractures
THOMAS SPLINT of the femur. Top: The line of
traction is in the line of the
femur, and the pad is low.
Gravity causes the fracture to
sag into posterior angulation.

Bottom: In Charnley's
modification, the Thomas splint
is placed posterior to the femur,
a pad is placed under the
fracture site, and the line of
traction is adjusted to pull below
the longitudinal axis of the
femur. This results in correction
of the deformity. (From Charnley
J. The Closed Treatment of
Common Fractures, 3rd ed.
Baltimore: Williams & Wilkins,
1963.)
BALKAN FRAME
RUSSELL’S TRACTION
SPLIT-RUSSEL TRACTION
UPPER FEMORAL
TRACTION
• Several traction
options for
acetabular
fracture
• Stretched
capsule and
ligamentum may
reduce
acetabular
fragments
• Pin insert 1 inch
from GT
 90-90 TRACTION

• Useful for subtroch and

proximal 3rd femur fx
• Especially in young
children
• Matches flexion of
proximal fragment
• Can cause flexion
contracture in adult
 BALANCED SUSPENSION WITH PEARSON
ATTACHMENT
• Enables elevation of limb to
correct angular
malalignment
• Counterweighted support
system
• Four suspension points
allow angular and rotational
control
 PEARSON ATTACHMENT

• Middle 3rd fx had mild flexion

prox fragment
• 30 degrees elevation with
traction in line with femur
• Distal 3rd fx has distal fragment
flexed post
• Knee should be flexed more
sharply
• Fulcrum at level fracture
• Traction at downward angle
• Reduces pull gastroc
SKELETAL TRACTION WITH A WESTERN BOOT
AGNES-HUNT TRACTION
TRACTION PIN PLACEMENT
• Sterile field with limb exposed
• Local anesthesia + sedation
• Insert pin from known area of neurovascular structure
• Distal femur: Medial  Lateral
• Proximal Tibial: Lateral  Medial
• Calcaneus: Medial  Lateral
• Place sterile dressing around pin site
• Place protective caps over sharp pin ends
PIN INSERTION SITE
 FEMORAL TRACTION PIN

• Must avoid suprapatellar

pouch, NV structures, and
growth plate in children
• Place just proximal to
adductor tubercle along
midcoronal plane
• At level proximal pole patella
in extended position
 DISTAL FEMORAL TRACTION

• Place pin from medial to lateral at the

adductor tubercle - slightly proximal to
epicondyle

Figures from Althausen PL, Hak DJ. Am J Orthop. 2002.

PROXIMAL TIBIAL TRACTION

• Used for distal 2/3 rd femoral

shaft fx
• Femoral pin allows
rotational moments
• Easy to avoid joint and
growth plate
• 1 inch distal and posterior to
tibial tubercle
 PROXIMAL TIBIAL TRACTION

• Place pin from lateral to

medial
• Cut skin and try to stay out
of anterior compartment -
push muscle posteriorly with
pin or hemostat

Figures from Althausen PL, Hak DJ. Am J Orthop. 2002.

CALCANEAL TRACTION
• May be used with a Bohler-
Braun frame
• Place pin medial to lateral 2 - Medial Structures
2.5 cm posterior and inferior to
medial malleolus

Figures from Althausen PL, Hak DJ. Am J Orthop. 2002. Lateral Structures
DISTAL TIBIAL TRACTION
• Useful in certain tibial
plateau fx
• Pin inserted 1.25 inches
proximal to tip medial
malleolus
• Avoid saphenous vein
• Place through fibula to avoid
peroneal nerve
• Maintain partial hip and
knee flexion
CALCANEAL TRACTION
• Temporary traction for tibial
shaft fx
• Insert about 1.5 inches
inferior and posterior to
medial malleolus
• Do not skewer subtalar joint
or NV bundle
• Maintain slight elevation leg
UPPER EXTREMITY TRACTION
FOREARM SKIN TRACTION

• Adhesive strip with Ace

wrap
• Useful for elevation in any
injury
• Risk is skin loss
DOUBLE SKIN TRACTION

• Used for greater tuberosity

or prox humeral shaft fx
• Arm abducted 30 degrees
• Elbow flexed 90 degrees
• 7-10 lbs on forearm
• 5-7 lbs on arm
• Risk of ischemia at
antecubital fossa
 DUNLOP’S TRACTION

• Used for supracondylar and

transcondylar fractures in
children
• Used when closed reduction
difficult or traumatic
• Forearm skin traction with
weight on upper arm
• Elbow flexed 45 degrees
OLECRANON PIN TRACTION
• Difficult supracondylar/distal
humerus fractures
• Greater traction forces
allowed
• Can make angular and
rotational corrections
• Place pin 1.25 inches distal
to tip
• Avoid ulnar nerve
 LATERAL OLECRANON TRACTION

• Used for humeral fractures

• Arm held in moderate
abduction
• Forearm in skin traction
• Excessive weight will
distract fracture
METACARPAL PIN TRACTION

• Used for obtaining difficult

reduction forearm/distal
radius fx
• Once reduction obtained,
pins can be incorporated in
cast
• Pin placed radial to ulnar
through base 2nd/3rd MC
• Stiffness intrinsics common
FINGER TRAPS

• Used for distal forearm

reductions
• Changing fingers imparts
radial/ulnar angulation
• Can get skin loss/necrosis
• Recommend no more than
20 minutes
SPINAL TRACTION
CERVICAL SKELETAL TRACTION

• Used to treat the unstable spine

• Pull along axis of spine
• Preserves alignment and volume of canal
• Gardner-Wells and Crutchfield tongs commonly used
GARDNER TONGS
• Easy to apply
• Place directly
cephalad to
external auditory
meatus
• In line with
mastoid process
• Just clear top of
ears
 CRUTCHFIELD TONGS

• Must incise skin and drill

cortex to place
• Rotate metal traction loop
so touches skull in
midsagittal plane
• Place directly above ext
auditory meatus
• Risks similar to Gardner
tongs
 HALO RING TRACTION
• Two anterior pins
• Placed in frontal bone groove
• Sup and lat to supraorbital
ridge
• Two posterior pins
• Placed posterior and superior
to external ear
Left: “Safe zone” for halo pins. Place anterior pins about 1 cm above orbital rim, over lateral
two thirds of the orbit, and below skull equator (widest circumference).
Right: “Safe zone” avoids temporalis muscle and fossa laterally, and supraorbital and
supatrochlear nerves and frontal sinus medially.
Posterior pin placement is much less critical because the lack of neuromuscular structures
and uniform thickness of the posterior skull.
Figure from: Botte MJ, et al. J Amer Acad Orthop Surg. 4(1): 44 – 53, 1996.
CRUTCHFIELD RECCOMENDATION
LUMBAL TRACTION
PELVIC SLING
DISCUSSION
THANK YOU